Intestinal disturbances associated with mortality of children with complicated severe malnutrition

Background Children admitted to hospital with complicated severe malnutrition (CSM) have high mortality despite compliance with standard WHO management guidelines. Limited data suggests a relationship between intestinal dysfunction and poor prognosis in CSM, but this has not been explicitly studied. This study aimed to evaluate the role of intestinal disturbances in CSM mortality. Methods A case-control study nested within a randomized control trial was conducted among children hospitalized with CSM in Kenya and Malawi. Children who died (cases, n = 68) were compared with those who were discharged, propensity matched to the cases on age, HIV and nutritional status (controls, n = 68) on fecal metabolomics that targeted about 70 commonly measured metabolites, and enteropathy markers: fecal myeloperoxidase (MPO), fecal calprotectin, and circulating intestinal fatty acid binding protein (I-FABP). Results The fecal metabolomes of cases show specific reductions in amino acids, monosaccharides, and microbial fermentation products, when compared to controls. SCFA levels did not differ between groups. The overall fecal metabolomics signature moderately differentiates cases from controls (AUC = 0.72). Enteropathy markers do not differ between groups overall, although serum I-FABP is elevated in cases in a sensitivity analysis among non-edematous children. Integrative analysis with systemic data suggests an indirect role of intestinal inflammation in the causal path of mortality. Conclusions Intestinal disturbances appear to have an indirect association with acute mortality. Findings of the study improve our understanding of pathophysiological pathways underlying mortality of children with CSM.

For all statistical analyses, confirm that the following items are present in in the figure legend, table legend, main text, or or Methods section.

n/a Confirmed
The exact sample size (n) for each experimental group/condition, given as as a discrete number and unit of of measurement A statement on on whether measurements were taken from distinct samples or or whether the same sample was measured repeatedly The statistical test(s) used AND whether they are one-or or two-sided Only common tests should be described solely by name; describe more complex techniques in the Methods section.

A description of of all covariates tested
A description of of any assumptions or or corrections, such as as tests of of normality and adjustment for multiple comparisons A full description of of the statistical parameters including central tendency (e.g.means) or or other basic estimates (e.g.regression coefficient) AND variation (e.g. standard deviation) or or associated estimates of of uncertainty (e.g.confidence intervals) For null hypothesis testing, the test statistic (e.g.F, t, r) with confidence intervals, effect sizes, degrees of of freedom and P value noted Give P values as exact values whenever suitable.
For Bayesian analysis, information on on the choice of of priors and Markov chain Monte Carlo settings For hierarchical and complex designs, identification of of the appropriate level for tests and full reporting of of outcomes Estimates of of effect sizes (e.g.Cohen's d, Pearson's r), ), indicating how they were calculated Our web collection on statistics for biologists contains articles on many of the points above.

Data analysis
For manuscripts utilizing custom algorithms or or software that are central to to the research but not yet described in published literature, software must be be made available to to editors and reviewers.We We strongly encourage code deposition in in a community repository (e.g.GitHub).See the Nature Portfolio guidelines for submitting code & software for further information.

Reporting for specific materials, systems and methods
We We require information from authors about some types of of materials, experimental systems and methods used in in many studies.Here, indicate whether each material, system or or method listed is is relevant to to your study.If If you are not sure if if a list item applies to to your research, read the appropriate section before selecting a response.The parent trial collected in-hospital clinical data from study participants recruited from 2 hospitals in in Kenya and 1 hospital in in Malawi between December 2014 and December 2015.

Materials & experimental systems
The outcome measure of of the nested case-control study was in-hospital mortality as as recorded based on on clinical data collected from the parent trial.